The role of imagination

Imagination is necessary in the work of exploring stories. A man says his chronic urticaria (‘hives’) began when he returned to his job after his summer break, only to discover that his employer had decided, without any warning, that he would now be working in a very different section of the company. Few of us would have any difficulty in imagining that this could be important to him emotionally, one way or another. The conjunction of urticaria and this work change may suggest there were some negatives or stresses involved. Such imagining could reasonably lead to the simple question of what did he feel about this turn of events, and so on.

Perhaps he responds with: ‘Oh, I just accepted it.’ Really? What was he accepting? I might imagine some more things: that he might not care, or that he might care and that he might be suppressing some feelings, or that he might not be used to expressing feelings, or that he might not see the point of discussing feelings because as far as he is concerned his hives is just a physical condition, or that his boss might be difficult and arbitrary and wouldn’t listen anyway, or that he felt he could not afford to upset his boss, and so on. Such imaginings reflect our experience of life. Because we know what life is like, in its ups and downs, and we can imagine some of the possibilities. But they should not be pushed onto the patient.

So, I persevere—remember that his urticaria began when he got the surprise news of job change. In this instance, I would probably say something like: ‘I am really interested that your hives came on at the time you returned to work and discovered this’; ‘Hives are often connected with things going on in our lives’; It is different for everybody, and in my experience people frequently get better when we look together at the connections’; ‘Thinking about it, what would have been the hardest thing about that surprise decision?’ And so on.

Because we know what life is like, in its ups and downs, and we can imagine some of the possibilities. But they should not be pushed onto the patient.

Eventually you and he begin to know together some of what he was really feeling. You have imagined there must have been some feelings. You have not imposed your story on his. You have let it emerge between you both. This kind of imagining is based on a belief that our lives are truly and continuously grounded in a constant sequence of feelings (positive and negative) that signal to us the meanings we make of our lives and circumstances, and that often we are not clearly in contact with them, and we are not aware that they can emerge as physical symptoms.